There is a textbook out on Acoustic Neuromas: ACOUSTIC TUMORS, Diagnosis and
Management, 2nd edition, which claims to be the authoritative book on this subject. It is
co-edited by William House, Charles Luetje, and Karen Doyle. It is supposed to be a
testament to their "continuing leadership in the AN field". Here is the blurb
for the book:

Updated and expanded, the second edition of this
classic text details state-of-the-art surgical techniques, presurgical
considerations, and follow-up protocols.

If this is the complete description of the book contents, it may be authoritative, but
it cannot be unbiased. This is like the ANA's disclaimer:

The ANA does not endorse any commercial product,
physician or surgeon, surgical procedure, medical institution or its staff.

This is also like a Nike spokesman saying he does not endorse any particular style
of sneaker, jogging or basketball, or whatever... It does not mean that you can't count on
him for info on Reebok shoes!

Isn't it strange that so authoritative a book does not discuss fractionated treatments?
FSR has been available since '94, at least. Any authoritative book from late 1996 should
have performed the due diligence of finding what seems to be the future of AN treatments
and to at least mention the results that have been reported so
far, however preliminary. After all, if someone told us they've found a way of jumping
out of a plane without a parachute at 10,000 feet, and surviving, and that 3 out of 3
people who've tried it have lived, we would pay attention despite such small numbers.

The following quote is typical of the advice in the textbook, which is mostly meant for
other surgeons:

There must be no waffling by the surgeon; rather a
genuine willingness to consider questions generated by the patient about alternatives must
be displayed and, if indicated, the surgeon must make changes.

At first reading, this may sound unbiased and fair. Yes, indeed, a surgeon must display
a willingness to consider patient questions about alternatives -- but for a different
reason that we patients may think: if the patient feels the need to get the answers elsewhere and finds a provider of radiosurgery, chances are very
good that they will not be back. There are many stories in the Archive to confirm
this. So this advice, that the proper strategy for a surgeon is to appear
willing to discuss alternatives, is really about maximizing their chances of getting the
patient's business.

It is indeed the case that many surgery patients say that the reason they knew surgery
is right for them when, instead of avoiding questions about alternative treatments, their
surgeons were very "open and honest" in discussing them. And again, it
sounds like a good thing. But invariably, such patients quote various AN myths that were told to them by their surgeon, which means that the
actual discussion was less than "open and honest".

This sounds like a reasonable statement, but there is unfortunately another
interpretation it: unless the above factors indicate a strong possibility of
life-threatening surgical complications, then surgery should be recommended...
Indeed, there are some surgeons with whom, no matter what the particular situation is,
every patient discovers they are precisely the ones who are indicated for surgery.
What happens when the surgical complications are not life-threatening, but are still
devastating to the patient's quality of life? Patient
beware!

And here is another quote:

There is no place for scare tactics or other
unethical methods to hustle a patient to the operative room to remove this benign tumor,
the surgery for which, though refined, carries the risks of injury to the cranial nerves,
brainstem, and cerebellum, as well as death.

Contrary to how it sounds to us patients, this does not advise surgeons that
they should help us avoid the operating room when there are alternatives that carry
smaller risks. It advices them to proceed "in such a way that you have the patient's
consent, so they are happy with their decision, and so they feel they were given enough
time and information to decide on their own". The idea is to avoid lawsuits
IF the risks do materialize, as well as to give the patient an incentive, as a willing
participant, to work harder at overcoming the resulting complications.

The passing nod that is given to radiosurgery in this book is culminated with the
following:

Physicians treating patients with acoustic tumors
should know about this treatment modality, its known potential morbidities, and the
uncertainties of long-term tumor control and long-term morbidity. The physician and the
fully informed patient then can proceed with the treatment program that is optimal for
that individual.

This paragraph confirms everything I said above. In particular, the need for the
patient to know outcome statistics for radiosurgery vs. surgery is not mentioned, yet the
it urges surgeons to tell patients about all kinds of "potential" and
"uncertain" stuff. This book is not in the business of telling surgeons to fully
inform patients, don't let the "fully informed" clause fool you. That clause is
legalese, with a very specific meaning, not the one we
patients would normally ascribe to it.

I know that some patients will saw this book as an unbiased authoritative resource; but
we see it as a summary of AN surgery marketing tactics -- what works and what does not --
shared by surgeons for the benefit of other surgeons, who may choose to use them to
attract more patients. We've read too many patient testimonials
that mirror this.